2014 Central Texas Annual Conference

Child Care Registration for

2014 Central Texas Annual Conference

Mansfield 1st United Methodist Church

777 N. Walnut Creek Drive, Mansfield 76063

817/477-2287 –

Children ages 3-months to 12 years are welcome. We will offer age appropriate activities.

Snacks will be provided but Children will need to bring their own lunch.

In order to secure your child/children a spot, a $20.00 NON-Refundable deposit per child is required along with your completed registration form. Final payment for childcare is due no later than Monday, 9-June-2014.

Parent(s) Name:______

Address______

Email:______

Home Phone:______Cell Phone:______

Children(s) Name Age(s) or Grade(s) Completed

______

______

______

Please indicate the times you will need DAYTIME child care:

Day/DateTime of Day K-6th Grade Age(s) 0-5 yrs.

Monday 9-June7:30am-5:50pm______$20.00 per child$20.00 per child

Tuesday 10-June7:30am-5:50pm______$20.00 per child$20.00 per child

Wednesday 11-June7:30am-5:50pm______$20.00 per child$20.00 per child

NOTE: Theamountsstated aboveareinadditiontothe$20.00NON-REFUNDABLEregistrationfeeperchild.

PersontocallinanEmergency(ifparentcannotbereached)

Name of person to call:______Phone #: ______Relationship: ______

IherebyauthorizeMansfield 1stUnitedMethodistChurchorconferencestaff/volunteersto allowmychildtoleavewiththe followingpersons(inadditiontotheaboveparent(s)

Name of person to call:______Phone #: ______Relationship: ______

Name of person to call:______Phone #: ______Relationship: ______

Please returnthesecompletedformswith$20.00NON-REFUNDABLEregistrationfeepriorto15-May-2014to:

AnnualConferenceChildCare,CTCUMC Attn:MavisHowell

464BaileyAvenue,FortWorth,TX76107

Email:

PleasecompletetheMedical/Informationsectiononpage2...._....

MEDICALINFORMATION

ThissectionmustbecompletedforallchildreninthedaytimeChildcareprogramofCTCUMC Annual Conference.

IntheeventthatI cannotbereachedtomakearrangementsforemergencymedical attentionformychild(ren). IherebyauthorizetheChildCareCoordinatorordesignatedparty toseekmedicalattentionasneeded.

Insurance Carrier: ______Policy #: ______

Listbelowanyknownallergiesofyourchild(ren):

Name(s) ofChild(ren) Allergic to:

______

______

______

______

Signature of Parent/GuardianDate

TRAVEL RELEASE:

Pleasecompletethefollowinginformationforanychild(ren)whohascompletedKindergarden through6thgrade.

Iherebygivemyconsentformychild(ren)namedbelowtotravelundersupervisiontotheplannedfield tripsandactivities scheduledformychild(ren)intheCentral TexasConference daytimechildcareprogramfor9;10;11-June-2014.I understandthatmychild(ren)issubjecttotherulesandregulationsoftheMansfield 1stUnitedMethodistChurchandthe leadersofthedaytimechildcare programoftheCentralTexasConferenceregardingbehaviorandpersonaldiscipline,andI herebyreleaseboth theMansfield 1stUnitedMethodistChurchandtheCentralTexasConferencefrom allliabilityfor injuriesorillnessresultingfrom circumstancesbeyondtheircontrol.

Name(s) ofChild(ren) Age(s) or grade completed in school

______

______

______

______

Signature of Parent/GuardianDate

Please returnthesecompletedformswith$20.00NON-REFUNDABLEregistrationfeepriorto15-May-2014to:

AnnualConferenceChildCare,CTCUMC Attn:MavisHowell

464BaileyAvenue, FortWorth, TX76107

Email: